Provider Demographics
NPI:1417186297
Name:GREENSBORO RADIATION ONCOLOGIST, PA
Entity Type:Organization
Organization Name:GREENSBORO RADIATION ONCOLOGIST, PA
Other - Org Name:TRIAD CARDIAC THORACIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:A
Authorized Official - Last Name:MANNING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-832-1100
Mailing Address - Street 1:PO BOX 13921
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27415-3921
Mailing Address - Country:US
Mailing Address - Phone:336-274-4285
Mailing Address - Fax:336-482-2177
Practice Address - Street 1:301 E WENDOVER AVE
Practice Address - Street 2:STE 411
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1230
Practice Address - Country:US
Practice Address - Phone:336-832-3200
Practice Address - Fax:336-482-2177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890167BMedicaid
NC890167BMedicaid